Provider Demographics
NPI:1548558836
Name:GLAD DENTAL P.C.
Entity Type:Organization
Organization Name:GLAD DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DATIKASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-404-5005
Mailing Address - Street 1:293 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5601
Mailing Address - Country:US
Mailing Address - Phone:646-404-5005
Mailing Address - Fax:646-404-5006
Practice Address - Street 1:293 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5601
Practice Address - Country:US
Practice Address - Phone:646-404-5005
Practice Address - Fax:646-404-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055422-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty